Leading into the Future

THIS lecture is in honor of Emery A. Rovenstine, M.D., who led the distinguished Department of Anesthesiology at Bellevue Hospital in New York, New York. Dr. Rovenstine was an early leader of the American Society of Anesthesiologists (ASA), and made a great impact in positioning the expanding specialty of anesthesiology for the challenges of the 20thcentury. As the heirs of Dr. Rovenstine, as the leaders of acute care medicine and perioperative health and safety, I have chosen to address an issue of leadership that affects all anesthesiologists: Where should we position ourselves as leaders in the healthcare delivery systems of the 21stcentury?Changes in society, in resource availability, in technology, pharmacology, genomics, and molecular biology, are converging upon healthcare systems worldwide. We must maintain excellence in clinical care, in education and research in the current care-delivery model, while accelerating our transformation to new forms of care delivery, new reimbursement models, and new configurations of skill sets. This will require leadership of the most broad and comprehensive stature, reaching deep into who we think we are and what we are capable of becoming. We need to drive change and take action across the broad scope of institutional and regulatory infrastructure, and do it ourselves, before changes impact us in a blindsided manner. We need to adapt to new healthcare delivery paradigms proactively to secure the profession for the future.One of the themes of the ensuing discussion is that these concepts are, in fact, not new; however, the urgency to address them now is high. Prior Rovenstine Lectures called these imperatives to our attention as early as 1996, to proactively deal with impending changes in health care, when David Longnecker, M.D., asked whether anesthesiology “is ready for the 21stcentury.”1Mark Warner, M.D., addressed similar themes in his 2005 Rovenstine Lecture,2for us to change anesthesia care delivery patterns ourselves, while the determinants are still open to our input. Ronald Miller, M.D., has written in ASA publications for a decade on these matters, challenging us to rethink the status quo.3–5At the University of California, Los Angeles (UCLA), we are currently taking stock of how to position a great medical school and a great health system to respond in innovative ways to the oncoming “disruptive” or “discontinuous” changes in health care, the type of change that occurs when long-held conceptual models are abruptly passed over for a new framework. Because discontinuous change is coming, including concepts such as population-based care, “full-risk” care, bundled payments, accountable care organizations, outcomes-based reimbursement, and so on, we all need to courageously lead into the future to prepare our practices and our institutions for change. The ideas that we are reexamining in this lecture have been available to us for some time.1–5Have we heard the messages? Are we prepared to change?“[How do we] respond in innovative ways to the oncoming ‘disruptive’ or ‘discontinuous’ changes in health care, the type of change that occurs when long-held conceptual models are abruptly passed over for a new framework?” In 2005, Dr. Warner urged us to be ready to change everything other than: 1) our commitment to patients who are critically ill or facing acute or chronic pain, including pain from procedures, or 2) our commitment to improve the care and safety of our patients. He commented: “Everything else – how we provide care, where we provide care, and how we are recognized for our care – financially, politically, or otherwise – is likely to change.”2Categorically speaking, whenever and wherever those changes come, we should not wait for others to determine our future, but rather step up to be the leaders of the transformation of the portion of healthcare delivery that is in our hands.The current imperative to be flexible and change is not limited to anesthesiology, and not even limited to medicine. The extent of new economic realities has meant that even Argentine cattle barons have had to face monumental change. As reported by the Los Angeles Times, with a headline, “Soy Sends Gauchos Into Sunset,” Argentine ranchers are rapidly adapting to economic reality and trading their long-traditional cattle herds for a new model of more profitable soybean crops. The Times wrote presciently for all professionals facing change, “economic reality … has trumped starry-eyed dreams of a storied past,” and quoted an agronomist advising former ranchers, “The world changes and your mind has to be open to it.”6As a profession, anesthesiology needs to be open-minded to clearly see the changes on the horizon, changes that require flexibility on former positions in order to be able to exercise leadership when new health system models come into being and/or step up to lead the redesign of those healthcare delivery models.My health system leadership work has reinforced for me that broad change is now the reality facing all physicians. An internist colleagues told me, “It's not just you, it is all of us. At our internal medicine meetings, that's all we talk about.” Internists indeed are faced with medical homes, with patient empowerment and self-management, with more pressure to reduce office visits and keep patients out of hospitals. Many internists are moving from their traditional solo or small group practices to join consolidated health systems that can take the financial risk to manage large populations on fixed fees.Figure 1illustrates how such large groups now see healthcare delivery. Resources are spent preventively to assist people to remain at the lowest levels of resource consumption for their state of health. The minority of a population needs acute care services, to be delivered based on systems optimization and outcomes measures. Much of the health-promoting activity of the future will happen outside of a formal healthcare site. Patients will measure their health parameters at home with direct wireless reporting. They will receive lab results online, adjust their own medications based on algorithms, utilize telephone or online consultations, and only rarely come to an office in person. The intermediate level of care will be provided by nonphysicians. Physicians will provide top-level, complex care, where their training and education is justified.Surgeons, too, are facing large changes to their roles and self-images, as their patient base is merging with patients seeking treatment from nonsurgeon interventionalists. Image-based surgery and treatment-based imaging are converging the domains of surgery and interventional radiology, surgery and the cardiac cath lab, surgery and the gastrointestinal procedure suite, and so on. Because radiology images can be read from any location, diagnostic radiologists are also being affected by technological healthcare delivery changes. Diagnostic radiologists at UCLA are now transforming themselves by partnering with our pathologists to establish combined diagnostic imaging and tissue sampling centers. Such centers will combine image interpretation, genomic biopsy reports, and advanced laboratory findings in one report.Pediatricians, too, face similar challenges to internists, and must utilize care delivery models that allow them to practice “at the top of their license” for the oversight, supervisory, and challenging aspects of pediatric care, while utilizing technology and ancillary providers for the straightforward elements of care. We too, need to ask: As anesthesiologists, are we leveraging our costly knowledge and skills to the greatest extent, to provide the components of the patient care process for which our education and training are necessary? How can we leverage our skills further to contribute more value, in addition to our acknowledged quality and safety, not only in the operating and interventional suites, but throughout the healthcare system?“We … need to ask: As anesthesiologists, are we leveraging our costly knowledge and skills to the greatest extent, to provide the components of the patient care process for which our education and training are necessary?” An example of upgrading of ancillary personnel to a higher level of their capabilities to support primary care is going on now in the UCLA Health System in response to external mandates for more care. The Center for Medicare and Medicaid Services now covers a comprehensive annual medical examination and preventive health counseling visit for every Medicare beneficiary, the so-called annual “Wellness Examination.” These extensive annual visits would not be sustainable if all elements were provided by a physician. In the UCLA primary care offices, already there are no costly nurses, only medical assistants, the “MAs,” who do the routine patient ancillary work of an office visit. Thus, a pilot program has been started by UCLA physicians to upgrade the capability of their MAs, through extensive training with a specified curriculum of lectures and hands-on experience. The goal of the training is for the MAs to achieve competence to do the preventive health interviews and basic preventive health counseling under the of the as as be in basic and other The will be able to the need for the extensive annual for all by and on the medical of the visit. 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